key: cord-338756-jzz250o1
authors: Zhang, Nan; Yao, Haochen; Zhang, Dong; Pan, Jiahui; Peng, Ejun; Huang, Juanjuan; Zhang, Yingli; Xu, Xiaoming; Tian, Guobao; Xu, Hong; Wang, Guoqing
title: Epidemiologic and clinical characteristics of 42 deaths caused by SARS-CoV-2 infection in Wuhan, China: A retrospective study
date: 2020-07-15
journal: Biosaf Health
DOI: 10.1016/j.bsheal.2020.07.007
sha: 
doc_id: 338756
cord_uid: jzz250o1

This study described the epidemiologic and clinical characteristics of patients who died from SARS-CoV-2 infection, and pointed out the potential risk factors associated with fatal outcomes. Retrospective data from 42 death cases due to SARS-CoV-2 infection at Tongji Hospital Affiliated to Huazhong University of Science and Technology, Wuhan, China was analyzed. Demographics, clinical detection, laboratory findings, and treatments of the deceased were collected and analyzed. The average time between onset of symptoms and admission to the hospitals was 11 ± 5 days of hospitalization. Among the deceased, 60% were with co-morbidities. All of them were having fever and bilateral pneumonia on computed tomography, abnormal infection-related biomarkers, and renal impairment. Abnormal blood coagulation parameters that appeared in more than half of them, were consistent with disseminated intravascular coagulation. All of the patients were treated in the ICU. Based on the fact that SARS-CoV-2 infection carries a risk of mortality, we may infer a few older male patients with underlying comorbidities are likely to have the increased risk. Impaired consciousness level, markers of renal impairment and coagulation abnormalities may be poor prognostic factors.

In December 2019, novel cases of pneumonia appeared in China, with its etiology known as SARS-CoV-2 [1] [2] [3] [4] [5] , predominantly were transmitted from human-to-human [6, 7] and clinical syndrome termed as -coronavirus disease 2019 (COVID-19)‖, by the World Health Organization (WHO). As of 25 February 2020, there had been 78064 laboratory-confirmed cases with 2715 fatalities caused by COVID-19, as reported in China [8] . The overall mortality rate was estimated as 3.4%, while that of critically ill patients, was 61,5% [9] . It seemed necessary to analyze the COVID-19 caused deaths and to understand the potential risk factors associated with the fatal outcomes.

In this retrospective study, we described the epidemiologic and clinical characteristics of 42 patients who died of COVID-19 infection. Hopefully, the epidemiologic data could help physicians better understand the COVID-19 infection, take appropriate actions on severe pneumonia, and reduce fatality, accordingly.

All the patients enrolled were confirmed of being infected by . The data of the 42 confirmed COVID-19 fatalities was collected from Jan 21 to Feb 14, 2020. The data includes, demographics, clinical symptoms, laboratory findings, and treatment.

All the patients were treated at Tongji Hospital Affiliated with HUST. SARS-CoV-2 infection was confirmed in accordance with the WHO interim guidelines. Data including age, gender, underlying diseases, clinical signs and symptoms, virus detection, computed tomography (CT) findings, treatments, routine blood and biochemistry, coagulation function, infection-related biomarkers, and routine urine etc., was gathered. Respiratory syncytial virus, adenovirus, and bacteria that caused pneumonia were also tested.

J o u r n a l P r e -p r o o f

Descriptive analyses were performed to display potential factors that might be associated with mortality related to the COVID-19 infection. SPSS (version 22.0) software was used. Continuous data were summarized as mean ± standard deviation (SD), or median (IQR, or interquartile range), with categorical data expressed in proportions.

All the 42 patients who died from COVID-19, including 30 males (30/42, 71%) were included in this study (Table 1) , with age distribution appeared as 69 ± 13 y (33-95 y) .

Of the 42 deaths, 25 (25/42, 60%) had more than one underlying known comorbidities, including 9 (9/42, 21%) with diabetes and 7 (7/42, 17%) with hypertension, 5 (5/42, 12%) with chronic cardiac or pulmonary disease, 3 (3/42, 7%) with chronic kidney disease, and 2 (2/42, 5%) with mild liver disease.

The most common symptoms appeared as fever (42/42, 100%), cough (32/42, 76%), dyspnea (32/42, 76%), shortness of breath (30/42, 71%), fatigue (16/42, 38%), chest pain (14/42, 33%), expectoration (13/42, 31%) and disturbance of consciousness (12/42, 29%). However, myalgia (6/42, 14%), arthralgia (4/42, 10%), headache (3/42, 7%), respiratory distress (3/42, 7%), hemoptysis (3/42, 7%), and rhinorrhea (1/42, 2%) appeared less frequently. All patients had undergone CT examinations and all of them presented bilateral pneumonia. Three patients were concurrently tested flu-positive. Higher levels of Aspartate aminotransferase (AST) was seen in 51% but γdecline transpeptidase (GGT) appeared low in 49%, of the patients. However, elevated alanine aminotransferase (ALT) appeared less common.

Most patients showed elevated levels of infection-related biomarkers, specifically on erythrocyte sedimentation rate (ESR) (88% of cases), serum ferritin (96%), C-reactive protein (100%), and serum procalcitonin (100%) ( Table 2 ). In most patients, concentrations of interleukin (IL)-2R, IL-10, and tumor necrosis factor alpha (TNF) also showed an increase in plasma and IL-6 was elevated in all the cases. Moreover, biochemical changes were consistent with renal impairment including microscopic proteinuria (93%) and hematuria (93%), hypocalcemia (78%), hyperphosphatemia, acidosis, elevated blood urea nitrogen (54%), and serum creatinine (35%) that appeared in many of the patients. More than half of the patients presented coagulation abnormality, including elevated activated partial thromboplastin time (APTT; 48%), prothrombin time (75%), decreased prothrombin activity (55%), and/or international normalized ratio (INR; 53%). The data suggested that disseminated intravascular coagulation (DIC) was associated with the outcomes of death, in patients with COVID-19 infection.

Different forms of treatment (Table 1) 

J o u r n a l P r e -p r o o f SARS-CoV-2 has been the seventh identified coronavirus, and ranking the third potentially lethal one, after SARS-CoV and MERS-CoV [1, [10] [11] [12] [13] . The present retrospective study aimed to analyze the demographic and clinical characteristics of patients who died of SARS-CoV-2 infection.

Forty-two patients died of confirmed COVID-19 infection were included in this study.

In the previous studies, characteristics and fatalities of the COVID-19 infection were summarized [3, 14] . The average survival time before death was within 1-2 weeks after admission to the ICU. Patients at older age (>65 years), with underlying diseases or ARDS were at higher risks of death [9] . Du et al [15] identified four predictors including age ≥ 65 years, preexisting concurrent cardiovascular or cerebrovascular diseases, CD3 + CD8 + T cells ≤ 75 cell/μL, and cardiac troponin I ≥ 0.05 ng/mL etc. were related to the fatality of COVID-19. In our cohort, more than half of the deaths occurred in older men with underlying diseases, especially diabetes and hypertension. However, still 40% of the deceased did not have any known underlying co-morbidity with COVID-19 infection. Common symptoms as fever, cough, expectoration, chest pain, dyspnea were all similar to reports from other researchers. However, 29% of these patients presented disturbance of consciousness, which to our knowledge, had not been mentioned in previous reports and may serve a marker for the poor outcome.

Among all the patients, 3 were co-infected of flu and COVID-19, confirmed by nucleic acid testings. All the patients showed signs of bilateral pneumonia on CT examination. As for laboratory findings, lymphocytopenia appeared in more than 90% of the deaths with COVID-19 infection, suggesting that the severity of lymphocytopenia might reflect the severity of COVID-19 infection. Elevated levels of infection-related biomarkers occurred in most of the patients while the elevated level of IL-6 was observed in all the cases. Moreover, many patients showed renal impairment to some degrees. It is noteworthy that patients with abnormal blood coagulation may indicate the presence of DIC, hence increasing the risk of mortality.

In terms of treatments involved, more than half of these patients received oxygen therapy and non-invasive ventilation, with a quarter of them underwent tracheotomy.

Potential risk factors associated with COVID-19 fatalities include being male and those with underlying comorbidities. However, 40% of the patients were without any known underlying comorbidities. Lymphopenia, ALP, high serum ferritin, hypoalbuminaemia/globulinaemia, C-reactive protein, serum levels of procalcitonin, IL-6, and markers of renal dysfunction appeared common in these patients. It must also be mentioned that more than half of the patients presented clotting abnormalities, which might serve as a marker for poor prognosis.

We hope that the information we have provided could highlight those conditions related to early warning on the risk of the COVID-19 fatalities, so as to reduce both the incidence of critical illness and mortality. 

Prior to conducting this study, we searched PubMed for articles up to 25 February 2020, using the keywords -2019 novel coronavirus‖, -2019-nCoV‖, or -COVID-19‖

and -epidemiologic and clinical characteristics‖ or -death‖, with no time restrictions.

We found one previously published article that discussed the clinical course and outcomes of critically ill patients with COVID-19. The study did not focus on the potential risk factors associated with a fatal outcome.

The mean time to admission from symptom onset was 11±5 days, the mean hospital stay was 5±4 days. Among the 42 patients, 71% were male, 60% had ≥1 co-morbidity.

All patients had fever and bilateral pneumonia on computed tomography, abnormal infection-related biomarkers, and renal impairment. Abnormal blood coagulation parameters seen in more than half of patients may be consistent with disseminated intravascular coagulation. All these patients were treated in the ICU.

This study demonstrated that COVID-19 carries a risk of mortality; based on this case series older men with underlying co-morbidities are likely at increased risk. Impaired consciousness level, markers of renal impairment and coagulation abnormalities may be poor prognostic factors

A Novel Coronavirus from Patients with Pneumonia in China

A novel coronavirus outbreak of global health concern

Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China

A pneumonia outbreak associated with a new coronavirus of probable bat origin

Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia

The authors thank all patients. This work was supported by grants from the